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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609763
Report Date: 07/22/2024
Date Signed: 07/22/2024 05:04:45 PM


Document Has Been Signed on 07/22/2024 05:04 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:BLUE SKIES RANCHFACILITY NUMBER:
197609763
ADMINISTRATOR:KRAKOVER, EILENEFACILITY TYPE:
740
ADDRESS:6061 SHIRLEY AVETELEPHONE:
(818) 730-4182
CITY:TARZANASTATE: CAZIP CODE:
91356
CAPACITY:6CENSUS: 4DATE:
07/22/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:08 PM
MET WITH:Eilene Krakover- AdministratorTIME COMPLETED:
05:00 PM
NARRATIVE
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In conjunction to the complaint number 31-AS-20230703161605 Licensing Program Analyst (LPA) Mariana Agban conducted a case management- Deficiencies visit. During the complaint investigation, LPA asked for R1 hospice records and Administrator had lost Hospice records for R1. LPA advised Administrator to keep all residents records for 3 years.

Exit interview conducted, citations issued and copy of this report delivered.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/22/2024 05:04 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: BLUE SKIES RANCH
FACILITY NUMBER: 197609763

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/05/2024
Section Cited
CCR
80070(f)

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 Original or photographic reproduction of all client records shall be retained for at least three years following termination of service to the client. This requirement was not met as evidenced by:
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Administrator will email LPA a statement of understanding this section by the POC date.
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Based on interview, Administrator lost hospice records for R1. This pose a potential health & safety risk to the residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024
LIC809 (FAS) - (06/04)
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